Physician Perspectives On Health IT

ICD coding

Texas Representative Ted Poe has introduced H.R. 2126, the Cutting Costly Codes Act of 2015. This legislation would prohibit the federal government from requiring physician offices to comply with the proposed transition to ICD-10 codes. “The new ICD-10 codes will not make one patient healthier," Representative Poe said. "What it will do is put an unnecessary strain on the medical community who should be focused on treating patients, not implementing a whole new bureaucratic language.” He has clearly listened to the Texas Medical Association (TMA) which has consistently advocated for postponement of ICD-10 on behalf of 48,000 physician members.

I am one of those Texas physicians who is thankful that a congressman has listened to us. If this bill were passed it would postpone ICD-10 and call for the GAO to study the issue, but it does not propose any solutions. Although I am in favor of this bill, I agree with the cry of many healthcare stakeholders that we need a solution to move away from the antiquated ICD-9 codes. It seems likely that a bill that does not propose an alternative solution will have difficulty getting passed.

I am hopeful, though, that debate about this bill might illuminate two major flaws in national health IT strategic planning. The current ICD-X strategy which includes no roadmap to ICD-11 will set up the U.S. healthcare industry for strife and conflict in the 2020s when we see the rest of the world leveraging integration between ICD-11 and SNOMED to improve quality of care and control costs while we struggle to gain value from what will then be an antiquated ICD-10 coding system.

The first flaw is the lack of a strategic plan or roadmap at a national level for ICD-X conversions. For example, there is no mention of ICD-10 or ICD-11 planning in ONC's Federal Health IT Strategic Plan 2015-2020. It is difficult to trust a strategic plan that fails to account for the tremendous burden that an ICD-10 and/or ICD-11 conversion brings to the healthcare industry. The ICD-10 tactical delays can be directly attributed to conflicting strategic national healthcare priorities which resulted in an overlap of initiatives at the local level--eRx requirements, Red Flag Rules, HITECH/HIPAA, Meaningful Use stages, PQRS, ambulatory EMR purchases/implementations/upgrades/updates and other healthcare regulations--and created unreasonable, concurrent burdens on physicians. Tactical delays like this can be avoided through more effective strategic planning at the national level.

It is particularly disconcerting that there is no national roadmap to ICD-11. As I previously wrote, the U.S. is planning to achieve a short-term tactical goal of replacing antiquated ICD-9 codes while the rest of the world is closing in on their long-term strategic goal of implementing ICD-11. Informatics experts are in agreement that ICD-11 is superior to ICD-10 and is much more integrated with SNOMED codes. In the 2020s I believe we will see the rest of the world successfully leveraging the benefits of ICD-11 and its tight integration with SNOMED to improve quality of care and control costs, while the U.S. is struggling to gain value from what will by then be antiquated ICD-10 codes. Cries for ICD-11 will crescendo, with most cries coming from those who do not see patients everyday. Without an ICD-11 roadmap, we will be destined for the same predicament, only this time struggling with a short-term tactical goal to replace last century’s ICD-10 codes with no strategic plan in place to align that burdensome effort with other healthcare priorities.

The second flaw is the lack of an effective process during ICD-X conversion planning to identify and address the concerns of grass root physicians who see patients every day. Failing to address physician concerns prior to developing the ICD-10 solution to the replacement of ICD-9 was a strategic blunder. Perhaps the most significant physician concern is the tremendous burden placed on physician practices by the ICD-10 conversion. Optimal planning on how to replace antiquated ICD-9 codes really should include discussions on how we might best reduce or avoid that burden. At the very least, we should discuss how best to reduce that burden in the future, because physicians see ICD-11 coming around the corner.

For example, we should discuss the possibility of converting from use of ICD-9 or ICD-10 to use of SNOMED codes in physician practices. Physicians would not have to learn new ICD-X codes each time administrators decide a conversion is necessary. Use of SNOMED codes mapped to ICD-X codes would be less disruptive to physician work flow and be more cost effective for physician practices as compared to complying with future ICD-X conversion mandates.

The analysis on how best to resolve the ICD-9 problem should address physician concerns and result in a strategic plan that is determined to have the highest potential to improve healthcare quality at the lowest cost. So what are some attributes of the optimal strategic planning effort? It would be included in ONC's federal health IT strategic plan. It would include a national roadmap to ICD-11. It would include a comparative analysis of the cost/benefits of completing a conversion of ICD-10 versus a direct conversion from ICD-9 to ICD-11. It would include an analysis of the potential to replace ICD-9 or ICD-10 codes in physician practices with SNOMED codes. And it would include a process to identify and address the concerns of physician practices throughout the planning stages.

I have consistently advocated for skipping ICD-10 and initiating an unprecedented effort to accelerate the development of ICD-11-CM. Although I still believe this strategy to be the one best aligned with quality care, I fear that the sunken ICD-10 costs are now so large that skipping ICD-10 is unpalatable for most organizations, even for some physicians, and is politically perilous. Since we must do something, I have been thinking more about the proposal to replace ICD-9 with SNOMED in physician practices. Leveraging SNOMED to improve care, lower costs and remove physician practices from the ICD conversion melees should be a serious national conversation at this point.

After several delays CMS has established October 1, 2015 as the new implementation date for the replacement of ICD-9 code sets used by medical coders and billers to report healthcare diagnoses and procedures with ICD-10 codes But another postponement remains a possibility--especially when one considers the unclear reasons for action taken by Congress earlier this year to call off the 2014 implementation. ICD conversion delays are costly to the healthcare industry and action should be taken to address the impediments that increase the risk of such delays. One of the major impediments to address is the adverse impact ICD conversions have on individual physician practices.

So let's jump out of the box of conventional charged impulses propagating across our cerebrums (thinking) to consider how to make ICD-10 optional for physician practices while still achieving our goal of dispensing with obsolete ICD-9 code sets. One alternative is to mandate physicians replace ICD-9 codes sets with SNOMED code sets and require EHRs to incorporate translator technology that converts SNOMED to ICD codes in the background. Since it would not be practicable to expect EHR vendors to incorporate the translator technology into their products by October 1, 2015, there would need to be an interim period where physician practices are exempt from the requirement to use ICD-10 codes sets until their EHR incorporates the translator technology. This alternative mandate allows the ICD-10 conversion to proceed for the rest of the healthcare industry including any physician practices who see value in completing their conversion. This mandate would reduce the current and future adverse impacts that ICD conversions have on physician practices, has higher potential to improve care, is more cost effective, helps EHRs be more user-friendly to physicians and mitigates the risk of further delays to ICD-10 as well as future ICD-X conversions.

I would anticipate a two-year transitional period where the ICD-10 conversion would be optional for physician practices based on an assumption that EHR vendors will need until 2017 to upgrade their products.

Some opposition among physicians is likely to be encountered due to their lack of familiarity with SNOMED as well as questions about how this alternative strategy adds value to patient care. I base that on the responses I heard from some respected colleagues at this weekend's Texas Medical Association meeting. The unfamiliarity issue can be addressed by pointing out that many of us are already using SNOMED, but that we just do not know it. CMS mandates that the problem lists in EHRs use SNOMED codes, so when one selects "Exercise-induced asthma" from a pick list of problems in their certified EHR, they are actually using SNOMED.

More difficult to articulate to physicians is how this proposal to convert from using ICD-9 to SNOMED codes in our EHRs would improve healthcare, how it would improve their work flow and how this is more cost effective for physicians as compared to complying with the current mandate. So I have developed the following bullet list to use when describing this to my colleagues:

Informatics experts are in agreement that ICD-9 is obsolete, and that although ICD-10 has potential to improve healthcare, ICD-11 and SNOMED have higher potential to improve healthcare.

SNOMED, which is interwoven in ICD-11's development, is inherently compatible with ICD-11 and is already required by CMS to be incorporated into certified EHRs for Problem Lists--thus, mandating use of SNOMED is not really new to physicians and will not result in an added cost to physicians

EHRs can be built with technology that automatically converts SNOMED codes into ICD codes--thus, mandating use of SNOMED is agnostic to the version of ICD-X being used; the cost to physicians of using the translating technology is very small as compared to the cost of finishing the conversion to ICD-10 and then converting to ICD-11 in the next 15 years.

After we convert to ICD-10 in 2015, discussions about implementing ICD-11 will ensue; since ICD-10 is over 20 years old and is less sophisticated than ICD-11, it will become apparent rather quickly that we need to convert to ICD-11 as soon as possible in order to improve healthcare (i.e. today's argument about ICD-9)

It takes the U.S. 7-10 years to refine the international version of ICD codes into the U.S. version we use--since the ICD-11 international version is expected to be completed in 2017, the earliest conversion to ICD-11 in the U.S. would be 2024 unless an unprecedented effort to accelerate development took place

In any case, converting to ICD-10 in 2015 will result in two ICD conversions in physician practices over the next 15 years. The proposed alternative strategy to convert physicians one time from ICD-9 to SNOMED results in just one conversion with all future ICD conversions occurring in the background without significant impact on physician practices--thus, mandating the use of SNOMED to replace ICD-9 would be a significant cost savings to physicians.

SNOMED codes have been developed for the purpose of clinical input; ICD codes are developed for important administrative and financial output purposes-- thus, use of SNOMED codes for input will improve physician work flow because SNOMED is more intuitive to use for physicians to describe clinical encounters; this also preserves the use of ICD code sets for the important administrative and financial functions that our healthcare system currently depends on.

I believe that if CMS is going to maintain their mandate to move off of ICD-9, then we should move on to an available coding system that has the most potential to improve healthcare at the lowest cost:

Informatics experts agree that ICD-11 is more sophisticated and has more potential to improve healthcare than ICD-10, but the earliest that a US version of ICD-11 could be available is 2024 unless an unprecedented effort to accelerate development occurs

On the other hand, SNOMED is already incorporated in EHRs and being used by physicians

Thus, I believe the mandate to convert off of ICD-9 is more likely to improve healthcare, improve physician work flow and impose the lowest costs if we make the 2015 conversion to ICD-10 optional for physician practices and mandate physicians start using SNOMED (with the translator technology incorporated in EHRs) in 2017. There will inevitably be tactical challenges involving diverse groups of healthcare stakeholders to work on, but if we remain aligned to the goal of improving quality care, I am confident we will find mutually agreeable solutions.

From a national policy perspective, ICD-11 is not found anywhere on the U.S. dial. Not even a preliminary roadmap to ICD-11 has been proposed. I believe this to be a serious risk to our nation’s health IT planning efforts, and this risk has been inherent to U.S. health IT planning for decades. The recent ICD-10 delay magnifies this strategic flaw. It is time for CMS to take a deep breath, re-evaluate our national strategy, address the unmitigated strategic risks and determine whether any mid-course corrections are needed before deciding on the new ICD-10 implementation date. It is time for the U.S. to begin implementing health IT smartly.

What I see right now is the U.S. planning to achieve a short-term tactical goal of getting off antiquated ICD-9 while the rest of the world is focusing on the long-term strategic goal of developing and adopting the new-century ICD-11. Unless we take action now, we are destined to be in the same predicament in the 2020s when we will be struggling to get off of last century’s ICD-10.

But the stakes will be much higher in the 2020s.

Most physicians and hospitals will be using EHRs, health information exchange will be flourishing, SNOMED-CT will be the common vocabulary used by clinicians and big data analysis will be... well, big. We will be stuck, though, with an ICD-10 taxonomy that was developed before the Internet came into common use. We will be clamoring for ICD-11 because it was developed in alignment with SNOMED and for other reasons I and others have previously described. Delays will likely be encountered. And we will probably be amnesic about how we got into such a predicament.

To avoid this we need a U.S. roadmap to ICD-11 before deciding when to implement ICD-10. We need to determine our long-term goals and then align our short-term tactical plans to those goals. What if ICD-10 is delayed another year? Would it then be time to leapfrog to ICD-11? What if the delay is 2 years? How about 3 years? Or maybe to meet our long-term goals it is actually time to leapfrog now. But without establishing long-term goals and developing a proposed roadmap to ICD-11, we cannot really make an informed decision.

Yes, we have to get off ICD-9, but not at any and all costs. I want the U.S. to change health IT planning efforts from one that risks derailment from ostrich-style decisions to one that smartly develops long-term strategic goals and aligns them to tactical plans. I want us to be a country that leads the world in the use of health IT to improve quality of care and one that smartly plans to optimize health IT use each decade.

ICD-10 is so “last century”. The United States did not adopt ICD-10 twenty years ago when the standard was first developed. The current version of ICD-10 that the United States is designated to adopt is based primarily on the international version of ICD-10 that the World Health Organization (WHO) published in 1990. The international version was drafted by committees that began their work over thirty years ago in 1982 (see 2nd Edition of ICD-10 by WHO). In other words, our version of ICD-10 is based on work done before use of the rich information space called the Internet became common and before the human genome was mapped.

ICD-11 is “this century”. According to an article in Healthcare Financing News, Christopher Chute who is one of the leading informatics experts and a Chairman of an ICD-11 Revision Steering Group at the World Health Organization stated:

“ICD-11 will be significantly more sophisticated, both from a computer science perspective and from a medical content and description perspective…. Each rubric in ICD-11 will have a fairly rich information space and metadata around it. It will have an English language definition, it will have logical linkages with attributes to SNOMED, it will have applicable genomic information and underpinnings linked to HUGO, human genome standard representations. ICD-10, as a point of contrast, provides a title, a string, a number, inclusion terms and an index. No definitions. No linkages because it was created before the Internet, let alone the semantic web. No rich information space.”

ICD-x codes are used by non-clinicians for important administrative and financial purposes. SNOMED-CT, on the other hand, is what physicians will actually use to communicate information about patients in their electronic health records (EHRs). In fact, physicians must use SNOMED vocabulary in their EHRs, not ICD-x codes, for their problem lists in order to achieve Stage 2 Meaningful Use for incentive payments and to avoid Medicare penalties in the future. Unlike ICD-10, ICD-11 is based on SNOMED. And SNOMED includes over 311,000 concepts with unique meanings, making it more granular than ICD-10 or ICD-11.

One way to think about the relationship is that SNOMED is the input and ICD-x is the output. SNOMED is used by clinicians to input clinical information into the EHR at a high level of detail. ICD-10 and ICD-11 aggregate that data into less detailed classifications that are more useful for output purposes such as quality reporting. They really cannot replace each other. But we could and should require EHRs to map in the background the SNOMED codes used by physicians into the ICD-x codes used by others. No need to engage physicians in ICD-x debates or to learn new vocabularies each time WHO does their thing with the U.S. traditionally following way behind.

So what the HIT are we thinking? Do we really believe that healthcare quality will be significantly improved based on ICD-10 that was developed out of work done over 30 years ago before the Internet was commonly used and before human genome coding was completed? Or do we believe that we need to adopt ICD-11 for output purposes and to use SNOMED–CT in EHRs for input purposes in order to move the quality needle in the right direction?

I for one believe that we need to get to ICD-11 as soon as possible. And I believe we should cut the umbilical cord to ICD-10 right now because:

There is currently no information showing that a conversion to ICD-10 is required before ICD-11.

It is intuitively obvious that the costs of going to ICD-11 directly from ICD-9 would be less than incurring the remaining costs of implementing ICD-10 in 2015 (or later) and then implementing ICD-11 sometime thereafter. And that includes the sunken ICD-10 costs. If you believe that this is an outrageous assumption, then prove it to be untrue. Show the comparative costs of both pathways. But don’t just comment or blog that it’s ridiculous without providing some kind of evidence. Sometimes it’s wisest to go with intuition.

The ICD-10 implementation has been so painful that it is unlikely the industry will have the stomach to move on to ICD-11 within a decade. This will result in an excessively long delay to ICD-11 and an excessive period of time using a classification system from the previous century.

There is consensus among leading informatics experts that ICD-11 is superior to ICD-10

Incidental to the AMA's opposition to the SGR fix bill is that they fail to actively support the one-year delay of ICD-10 that is included in that bill. Interesting ploy--oppose a bill that you could live with. If their opposition fails to change minds and the bill is passed, they are not blamed by others for the ICD-10 delay and they are not blamed by us physicians for not trying to fix SGR. They get a delay in ICD-10 and they begin hard work to fix SGR next time. On the other hand, there is obviously no luxury of a "next time" for an ICD-10 delay once the implementation starts.

And, by the way, the dream of skipping ICD-10 and moving to ICD-11 sooner momentarily flickered in my head last night. The cost analysis of the two possible pathways to ICD-11 would still be interesting. However, I recognize that the sunken costs into the current pathway to ICD-11 (through an ICD-10 implementation) have grown exponentially since I wrote that blog.

ICD-11 could be implemented within 7 years if we are determined to do so. But once we implement ICD-10 I fear the industry will not be able to stomach an ICD-11 implementation within a decade. And if the ICD-10 implementation is a debacle, then I believe thinking about ICD-11 will cause such nausea that it will be delayed 15-20 years. For ICD-11's sake, I hope the one-year delay holds up in order to mitigate the chances of an ICD-10 debacle this year.

The American Medical Association (AMA) failed to complete their homework assignment before concluding in a report that skipping ICD-10 to move directly to ICD-11 is not a feasible option. Just like CMS (see CMS prematurely dismisses the alternative option to forgo ICD-10 and implement ICD-11), the AMA failed to compare the total cost of implementing ICD-10 and then implementing ICD-11 to the total cost of foregoing ICD-10 to implement ICD-11 sooner. To make matters worse, the AMA's report openly states that they only performed a preliminary assessment of the feasibility of moving from ICD-9 directly to ICD-11. Since when does one draw a final conclusion based on a preliminary assessment?

Several statements in the report lead me to believe that the AMA prematurely issued this report without performing a comprehensive analysis in order to maintain political relationships with other healthcare stakeholders. For example, the AMA states that "while many physicians have concerns about the costs and burden of ICD-10, there are many other stakeholders, including 24 government agencies, researchers, large payers, large health system providers, and public health entities, that support the conversion." OK, let's think about that...the AMA acknowledges that physicians are concerned about the costs, and yet they offer no comparative analysis of the costs. Which relationships have the appearance of being more important to the AMA in this case: physicians or others?

The AMA states that "stakeholders have already invested millions towards the adoption of ICD-10." This is certainly true, but I do not see these sunken costs as an obvious reason to eliminate the ICD-11 option. Instead, I see these costs as one of the important variables in a simple equation:

Is x greater than or less than y? As a physician I expect my professional organization to actually do the math before writing down an answer.

And finally, the AMA makes an argument for ICD-10 because "some have speculated" that it could take 20 years to implement ICD-11. This is really quite embarrassing, as even CMS stated in their ICD-10 final rule that ICD-11 could be implemented as early as 2020. In a recent Health Affairs report informatics experts speculate that an accelerated ICD-11 implementation could occur in 5-7 years, and they are in agreement that we need to transition to ICD-11 sooner than 20 years from now.

I recognize AMA as a strong advocate for physicians, but I give the organization an "F" on this homework assignment.

"The decision to mandate ICD-10 for covered entities has already been made."

This response in the ICD-10 final rule published last Friday by the Department of Health and Human Services (HHS) bluntly spurns the option of foregoing ICD-10 to implement ICD-11. HHS predictably argues that the considerable investments already made by healthcare organizations into ICD-10, the years of rulemaking with previous analyses of ICD-10 value/costs and the "uncertainties" over the timeline and value of ICD-11 all justify a decision to eliminate ICD-11 as an option.

I am disappointed that HHS made no estimates on the comparative value of ICD-10 to ICD-11. Instead of comparing the total cost of proceeding with ICD-10 and then implementing ICD-11 to the total cost of foregoing ICD-10 to implement ICD-11, HHS candidly explains that "we do not participate in this debate in this rule, except to say that we are convinced of the benefit of ICD-10 to health care delivery in this country." There clearly was no intent to revisit a previous decision to implement ICD-10, even though there is an opportunity to gather and analyze new information to assure we make an informed decision on the optimal pathway to an inevitable ICD-11 implementation.

The final rule dismisses the call from several commenters on the proposed rule for an analysis of the total costs of the two pathways to an ICD-11 implementation. One argument made against such an analysis is that the "the disruption and costs of transitioning to ICD-11 are highly unlikely to be less those of transitioning to ICD-10." I agree that each individual implementation may have comparable costs, but that does not compare the cost of the two pathways which are:

What is the comparable cost of each pathway? A comparison of the cost and benefits could have a significant impact on the decision. Let's learn from this for next time.

By the way, there will soon be a next time. I fear that this decision locks the U.S. into another cycle of the same-- using a diagnosis coding system that rapidly becomes archaic and leads to another decade of desperate efforts into the 2030s to upgrade after the rest of the world has already transitioned to ICD-11.

I also fear that that the burden will be excessive on healthcare organizations in 2014 to implement ICD-10 and meet the 2014 Stage 2 Meaningful Use requirements which were both announced by CMS this week. This burden will be greatest on the small, individual physician practices are already throttled by meaningful use, 5010, e-prescribing and healthcare reform. They are struggling to find the time and resources for the ICD-10 effort. Since the EHR Incentive Program has a specified timeline under ARRA, I believe this excessive burden is likely to trigger another delay of ICD-10, at least for small physician practices.

Will we be left wondering why we didn't just stop investing in ICD-10 back in 2012?